MD.Salutis

KIDNEY CYST

noreply@blogger.com (Dr. Pedro Pinheiro) — Mon, 16 Nov 2009 00:16:00 +0000

More than once I've attended patients who came to me (nephrologist), terrified with the cyst in the kidney accidentally found in a image exam, usually abdominal ultrasound.

Renal cysts are commonly observed in normal kidneys, with an increasing incidence as individuals age. They are benign asymptomatic lesions.

The principal clinical concern about renal cysts is the distinction between a malignant lesion that looks like a cyst and the real cysts. That's why we usually use the terms "simple cyst" and "complex cysts". The former means a benign cyst without features of malignant disease. The latter refers to cysts that has some characteristics that could indicate a disguised malignant lesion.

One might say that simple renal cyst is the white hair of the kidney. Everyone will get yours as age comes. Simple renal cysts may be solitary or multiple and bilateral. They typically produce no symptoms or signs.

It is so common that, people over 60 may have up to 4 cysts in each kidney and it does not mean any disease. If it is very common in elderly, is not unusual bellow 50 years, and, you don't expect to find even one renal cyst bellow 30 years.

The finding of a cyst in young adults or multiple cysts in older adults might indicate a disease called polycystic kidney disease.

Rarely, a simple cyst can be associated with rupture (hemorrhage), hematuria, pain, abdominal mass, infection, and/or hypertension.

It's important to highlight that a simple cyst NEVER becomes a cancer. What sometimes might happens is a misdiagnosed complex cyst. But it's rare.

The ultrasound, at most of the times, easily distinguishes the simple from the complex cysts. When a doubt arises, the doctor asks for a CT scanning to better understand the image.

To help diagnose and manage these lesions, the Bosniak renal cyst classification system was created. It's divided in four categories as shown bellow

- Category I — This is a benign simple cyst with a thin wall without septa, calcifications, or solid components.

- Category II — These are benign cystic lesions in which there may be a few thin septa; the wall or septa may contain fine calcification or a short segment of slightly thickened calcification. It is not cancer.

- Category III — These are indeterminate cystic masses that have thickened irregular or smooth walls or septa. Approximately 40 to 60 percent are malignant The remainder, such as hemorrhagic cysts, chronic infected cysts, and multiloculated cystic nephroma, can not be considered simple cysts, but are still benign lesions.

- Category IV — These lesions (85 to 100 percent of which are malignant) have all the characteristics of category III cysts plus they contain enhancing soft-tissue components that are adjacent to and independent of the wall or septum.
If you have a category I ou II kidney cysts, no further evaluation are necessary except a ultrasonography every 12-24 months to assure stability of the image.

If you have a Bosniak category III cyst, you must be undergo more specific evaluation. It can be done with a Magnetic resonance imaging and image-guided biopsy or surgical evaluation.

Category IV lesions require surgery, as approximately 85 to 100 percent are malignant.

So, you went through a ultrasound exam and the report says: simple kidney cyst, you can relax because nothing serious was diagnosed.

Portuguese Version: CISTO RENAL

RABIES SYMPTOMS AND TREATMENT

noreply@blogger.com (Dr. Pedro Pinheiro) — Sun, 01 Nov 2009 20:47:00 +0000

Portuguese version: RAIVA HUMANA

Rabies is a zoonosis (a disease transmitted from animals to humans) caused by a virus. It is one of the most serious diseases known. The mortality is almost 100%. No other infectious disease has a mortality rate as high. Although there is an effective vaccine, each year approximately 70,000 people worldwide still die from rabies.

The rabies virus is transmitted by bites and scratches from infected mammals. In most cases the transmission occurs through dogs and cats. However, several other mammals can transmit the disease, including:

- Ferrets
- Foxes
- Coyotes
- Raccoons
- Skunks
- Bats

Rodents such as squirrels, rats, rabbits and hamsters are not common transmitters of rabies. There are very few human cases caused by one of them.

Non-mammalian animals such as lizards, fish and birds DO NOT transmit rabies.

Symptoms of rabies

The rabies virus has tropism for the central nervous system, i.e, it is a neuroinvasive viral disease that causes acute encephalitis (inflammation of the brain).

Symptoms of rabies are all due to this involvement of the brain:

- Confusion
- Disorientation
- Aggressiveness
- Hallucinations
- Difficulty swallowing
- Motor paralysis
- Seizures
- Excessive salivation

Once started the neurological symptoms, the patient progresses to death in 99.99% of cases. To date (September 2009), that are only 3 reported cases where the patient survived. These three cases are the result of a new treatment regimen first described in 2005 which includes an antiviral (Ribavirin), an anesthetic (Ketamine) and an anxiolytic (Midazolan). However, despite the cure, the sequels are severe.

The evolution of rabies can be divided into 4 stages:

1.) Incubation - The virus spreads through the peripheral nerves slowly. From the bite to the onset of neurological symptoms there is usually a range of 1 to 3 months.

2.) Prodromes - They are non-specific symptoms that occur prior to encephalitis. Usually consists of headache, malaise, fever, sore throat and vomiting. There may also be numbness, pain and itching at the site of the bite or scratch.

3.) Encephalitis - is the manifestation of inflammation of the central nervous system as previously described.

4.) Coma and death - Occur on average 2 weeks after the onset of symptoms.

Treatment of rabies

If on one hand virtually 100% of patients die after the onset of symptoms, on the other, there is a vaccine and a prophylactic treatment with immunoglobulins (antibodies) in the event of exposure to the virus.

If bitten by a mammal, you should wash the wound with soap and water and move toward a health facility.

If the animal is domestic is important to know its vaccination data. It must be attested that the dog or cat is immunized against rabies. In domestic animals, the incubation period is usually within 10 days. This is the period in which the animal must be observed. If after 10 days it remains healthy, there is no risk of contracting rabies.

If the animal is wild like a bat, it is important to capture it, so it can be analyzed. If you can not capture the animal, the treatment should be started assuming that it has rabies. The same goes for street dogs and cats that manage to escape.

Bites on the head and neck are the most serious ones, because they are close to the brain. In this case, the travel length to the brain is much shorter than, say, a bite on the legs.

Unless there is an open sore on the skin, one cannot get rabies only from touching or being licked by an animal. But the old habit of offering wounds to be licked by a dog, not only facilitates a bacterial infection, as it can also transmit rabies, given that the virus resides on the animal's saliva.

The post-exposure prophylaxis (after bites from suspected animals ) should be started as soon as possible. There are several schemes involving vaccines and immunoglobulins. Depending on the severity of the injury, the schema can include up to 10 days of vaccination followed by daily administration of immunoglobulin.

It is also important to get immunized against tetanus, if the last vaccination has more than 10 years. In addition to tetanus and rabies, animal bites can become infected and antibiotics may be necessary.

Bites from Bats

Bats are animals commonly infected by rabies. In the U.S. the past 15 years, more than 90% of rabies cases were caused by bat bites.

The big problem is that the bite may go unnoticed, especially if it occurs while the victim sleeps. Therefore, treatment is indicated for those who wake up and find a bat in your room, even with no signs of bite or scratch. As rabies is very lethal, when in doubt, you should always assume that the bite has happened.

It is important to understand the seriousness of rabies. You should never overlook a bite or scratch by animals. Do not rely solely on the appearance of the animal to determine that it is not sick. Once bitten, you should seek medical assistance immediately.

PREGNANCY SYMPTOMS / PREGNANCY TEST

noreply@blogger.com (Dr. Pedro Pinheiro) — Thu, 22 Oct 2009 19:34:00 +0000

Spanish version: SÍNTOMAS DE EMBARAZO | PRUEBA DE EMBARAZO
Portuguese version: SINTOMAS DE GRAVIDEZ / TESTE DE GRAVIDEZ

"Am I pregnant?"

How many women have asked this question before?

What are the symptoms of early pregnancy and what are the best tests to diagnose it?

The most reliable method to diagnose a pregnancy is the measurement of a hormone called human chorionic gonadotropin (hCG) in the boold. Most tests employ a monoclonal antibody, which is specific to the β-subunit of hCG (β-hCG).

The levels of beta hCG begin to rise after 8 days of fertilization, just after the implantation of the egg in the uterus.

- Values of hCG under 5 mIU/ml are negative
- Between 5 and 25 mIU /ml it is inconclusive and can mean very recent pregnancy. You should repeat the test in 3 days.
- Values above 25 mIU/ml indicates pregnancy.

During the first 30 days, the value of beta hCG approximately doubles every 24-48 hours and can reach up to 150,000 mIU/ml at 10 weeks gestation. After that, this value decreases, stabilizing at around 10,000 mIU / ml.

hCG is measured in laboratories and most women prefer more convenient methods that can be done at home without need for needles to collect blood.

Therefore, since the 1970s there are home pregnancy tests. They are simple strips that can detect the presence of hCG in urine.

As the concentration of hCG in urine is lower than in the blood, the pharmacy tests take longer to become positive. While the blood beta hCG assay may be positive on the first day of a missed period, the beta hCG in the urinary assay is more reliable when made after 1 or 2 weeks, to avoid false negatives. The more advanced the pregnancy, the greater is the level of blood hCG, and consequently, the greater the level of urine hCG. After 1-2 weeks of a missed period, the sensitivity of the home tests reaches 99%.

It does not mean that you can't take the pharmacy test on the first day of missed period, however, must take into account the risk of false negative. Therefore, if the test is negative, you have to repeat it after 1 week, if your period is still delayed.

In more advanced pregnancies we can identify the gestational sac from the 5th and 7th weeks by transvaginal or abdominal ultrasonography, respectively.

Surprisingly, some women do not seek diagnosis to the last stages of pregnancy. Sometimes the pregnancy is so obvious that we can identify it by physical examination. At 12 weeks the uterus begins to be palpable, and after 20 weeks can identify fetal heartbeat with a stethoscope (which are around 160 beats per minute, much faster than the mother's) and notice their movements by abdominal palpation.

Early diagnosis of pregnancy is important to initiate early prenatal care. In addition to controlling blood pressure and glucose levels, recognition of pregnancy is important to avoid alcohol and medications that are harmful to the fetus.

What are the symptoms of pregnancy?

a.) Delayed menstruation

The most obvious is the absence of menstruation. All sexually active women in reproductive age, with more than 1 week of menstruation delay, should think about pregnancy. In women with irregular cycles, these failures are more difficult to assess.

Another problem is that some women have small periodic bleeding in early pregnancy, which might be mistaken by a weak menstruation. There is also the possibility of minor bleeding during implantation of the fertilized egg in the uterus. This usually occur 10 to 14 days after fertilization, more or less at the time expected for your period to come, contributing to confusion.
b) Nausea and vomiting

A classic symptom is nausea and vomiting during weeks 6 and 12 of pregnancy. These symptoms tend to be worse in the morning and improve during the day.

If there are symptoms such as diarrhea, severe cramping or fever, other causes should be investigated as well.

c) Aching and swollen breasts

hCG and increased estrogen and progesterone promote mammary gland stimulation, which leads to an increased volume of the breast, local pain and darkening of the nipples.

d) Fatigue

More common in the first trimester, fatigue is probably caused by increased levels of progesterone

e.) Frequent urination

A frequent need to urinate, usually associated with sleep disruption and the need to get up at night to urinate, are common. This is due to changes in the kidney, mainly because of increased sodium excretion.

f) Other common symptoms

- Wishes and food aversions
- Mood swings
- Constipation
- Heartburn
- Dizziness
- Headaches
- Backache

UNDERSTAND HYPERTENSION (HIGH BLOOD PRESSURE)

noreply@blogger.com (Dr. Pedro Pinheiro) — Thu, 15 Oct 2009 16:29:00 +0000

Portuguese version: SINTOMAS E TRATAMENTO DA HIPERTENSÃO

One of the major problems of hypertension (high blood pressure) is the fact that it is asymptomatic until advanced stages. To assume that the pressure is high or normal based on symptoms such as headache, fatigue, pain in the neck or eyes, feeling of heaviness in the legs or palpitations, is a very common mistake among patients.

Another mistake is to evaluate the blood pressure based only in one isolated measure. A hypertensive patient may have times of day when the pressure is within or near the normal range, as well as, a person without hypertension may have high pressure due to factors such as stress and physical exertion. So we do not make the diagnosis or rule out hypertension based on only one measure.

Several factors can alter the pressure from time to time, among them are stress, physical exertion, use of alcohol or cigarettes etc ... People tend to measure the blood pressure after events of emotional stress or headache, situations which in itself can increase its levels.

To make the diagnosis of hypertension we need from 3 to 6 high measurements carried out on different days, with a range greater than 1 month between the first and last measurement. This way, we minimize the confounding external factors.

If after that there is still doubt, the ideal is to request an ABPM (Ambulatory Blood Pressure Monitoring). The ABPM is basically a blood pressure device, which is in the patient's arm for 24 hours, checking his blood pressure several times a day, covering all common daily situations such as sleeping, eating, working etc ...

Persons with over 50% of measurements above normal range are considered hypertensive. Between 20% and 40% are people at high risk of developing hypertension, which already implicate changes in lifestyle and diet. Normal people have controlled pressure by more than 80% time of the day.

The most accepted definition on hypertension today is as follows:

Normotensive: pressures less than or equal to 120/80 mmHg
Pre-hypertensive: pressures between 121/81 - 139/89 mmHg
Hypertensive grade I: pressures between 140/90 - 159/99 mmHg
Hypertensive grade II: Pressures greater than or equal to 160/100 mmHg

White coat hypertension

The white coat hypertension happens to patients who only have high blood pressure during medical visits. These are people who gets anxious in the presence of the physician and they’re pressure rises immediately. Sometimes it is difficult to differentiate them from true hypertension. In general it is necessary to perform the ABPM to be sure.

The white coat hypertension is not hypertension itself, but it affects people who are more likely to develop it. Therefore, the white coat hypertension is a risk factor for hypertension and also implicate real changes in lifestyle to prevent the progression of the established disease.

Hypertension is associated with several serious illnesses such as:

- Heart failure
- Myocardial infarction
- Cardiac arrhythmia
- Sudden Death
- Aneurysms
- Loss of vision (hypertensive retinopathy)
- Chronic renal failure
- Ischemic and hemorrhagic stroke
- Dementia micro infarcts.
- Arteriosclerosis

Hypertension is rarely curable and the goal of the treatment is to avoid that major organs as the heart, eyes, brain and kidneys don’t suffer injuries that will cause the diseases described above. These are the so-called target organs.

As already mentioned, the initial lesions of hypertension are asymptomatic, however, there are tests that can detect them early.

KIDNEY

An early manifestation of renal damage by high pressure is the presence of protein in urine, called proteinuria. These proteins can be detected easily through a simple urine dipstick test. Small amounts of protein cause no symptoms. Advanced renal lesions lead to major proteinurias, manifested as foamy urine. Another sign of advanced disease is the elevated blood level of creatinine.

High blood pressure untreated can, in the long term, lead to kidney failure and hemodialysis.

EYES

Hypertension leads to damage of blood vessels that irrigate the eyes causing progressive loss of vision. An examination of the eye by the ophthalmologist can reveal an early injury that hasn’t cause symptoms. It's that simple test in which the doctor dilates the pupil and then observes the eye with a special flashlight.

Compare the 2 pictures below from an ophthalmoscopy. The first is a normal eye. The second is an eye with advanced hypertensive retinopathy. The red spots are hemorrhages, and the bright spots are pus secondary to the inflammation. Note the deformity of the vessels.

HEART

The heart is perhaps the organ which suffers the most from a high blood pressure. Hypertension make it harder for the heart to pump the blood as there is a high resistance to overcome. The heart is a muscle and as such it becomes hypertrophied (increased muscle mass) when subjected to chronic stress. A heart with increased muscle mass, has a smaller space in its cavity to receive blood. This is called diastolic dysfunction.

Therefore, left ventricular hypertrophy and diastolic dysfunction are the earliest signs of cardiac stress by hypertension. It can be detected on a electrocardiogram, but are best seen on an echocardiography.

Like a rubber band that for a long time has been strained and lost its elasticity, getting loose, the heart after years of stress on high blood pressure begins to dilate and lose the ability to pump blood. To this stage is given the name of heart failure.

BRAIN

One of the most important risk factors for stroke is hypertension.

The hypertension can lead to small repeated strokes that do not cause major neurological sequel at first. As time passes and hypertension is not controlled, these small lesions will multiply, being responsible for the deaths of thousands of neurons. The patient begins to present a progressive state of loss of his intellectual abilities that often go unnoticed by the family in the early stages, but in the end, it leads to a state called multi-infarct dementia or vascular dementia.

Most often target organs lesions can be reversed if treated in time. But for this, it’s necessary to be aware that hypertension should be treated before symptoms of target organ lesions appear, and not after.

The main risk factors for hypertension are:

- African American
- Obesity
- High consumption of salt
- Consumption of alcohol
- Sedentary
- High cholesterol
- Obstructive sleep apnea
- Smoking

Once diagnosed, all patients should undergo changes in lifestyle before starting drug therapy. The main ones are:

- Weight reduction
- Start exercising
- Quit smoking
- Reduce the consumption of alcohol
- Reduce salt intake
- Reduce consumption of saturated fat
- Increase consumption of fruits and vegetables

Those patients who have come to the doctor with high blood pressure and signs of target organ damage, should begin drug treatment as soon as it indicates long-standing hypertension.

Only patients with signs of target organ damage, chronic renal failure, diabetes or heart disease should start drug treatment immediately. Obviously, changes in lifestyle are also needed in this group.

The problem is that most patients can not accept changes in lifestyle and end up taking medication to control blood pressure.

The pressure reduction with these life style changes is usually small and hardly a person with very high blood pressure (> 160 x 100 mm Hg) can control it without the help of drugs.

Treatment of hypertension

Numerous drugs are used to treat hypertension, the major options are:

1.) Thiazide diuretics.

Ex: Hydrochlorothiazide, Indapamide and Chlorthalidone

Cheap drug with great results. If it is not the first choice, it should be the second.

They are excellent antihypertensive drugs for black people and elderly.

Very high doses can interfere with glucose control in diabetics. Diuretics increase the uric acid and should be avoided in those with gout.

The Lasix (furosemide) is a diuretic and another class is not indicated as treatment for hypertension, except in patients with heart failure or chronic renal failure.

2.) ACE inhibitors and angiotensin receptor blockers

Ex: Captopril, enalapril, ramipril, lisinopril, losartan, candesartan, olmesartan

Also an excellent drug to control blood pressure. Indicated mainly for young people or patients with cardiovascular disease, chronic renal failure and proteinuria.

Not a very good choice for black people since it seems not to work so well. Another problem is that it can raise the blood potassium and cause allergies in some patients.

3.) Inhibitors, calcium channel

Ex: Nifedipine and Amlodipine

Best choice for black peoples and very good for the elderly. However, it can be used in any group of patients.

Some people present edema (swelling) in the lower limbs as a side effect.

4.) Beta-blockers

Ex: Propranolol, Atenolol, Carvediolo, metoprolol, bisoprolol

Inferior than the previous 3, but should be first choice for patients with cardiovascular disease, cardiac arrhythmias, migraine headaches, hyperthyroidism and anxious people with trembling hands.

Should not be used for asthmatics and people with heart rate below 60 per minute.

More than 90% of hypertensive patients have to take 1 or more of the remedies described above. to control its blood pressure.

Patients with benign prostatic hyperplasia should use another class called alpha blockers such as Prazosin and Doxazosin. These “2nd line” drugs should not be prescribed in other groups.

Some people have hypertension difficult to control and, sometimes, need 4, 5 or 6 antihypertensive drugs.

In this case there are alternatives such as hydralazine, methyldopa, clonidine and minoxidil, potent drugs, used in severe cases.

CANKER SORE TREATMENT

noreply@blogger.com (Dr. Pedro Pinheiro) — Fri, 02 Oct 2009 13:49:00 +0000

Spanish Version: AFTAS BUCALES | Causas y tratamiento
Portuguese version: CAUSAS E TRATAMENTO DA AFTA

Oral ulcers, also called aphthous ulcers or canker sore, are very common lesions of the oral mucosa.

Canker sores are benign lesions, but sometimes, some serious diseases may appear with very similar lesions.

Let us first talk about the simple aphthous ulcer, and then, describe the others oral ulcers that deserve more attention.

What is canker sore?

Canker sore is an ulcer that can arise anywhere in the oral cavity: tongue, lips, gums, throat and uvula. The lesions are oval, whitish (sometimes yellow), shallow and clean, i.e, do not have pus, bacteria or other signs of infection. They may be single or multiple, small or large.

Canker sore

Everyone has had at least one during lifetime and 20% of the population suffers from recurrent ulcers. They are more common in pre-adolescents, adolescents and young adults, tending to decrease its incidence over the years.

Despite being benign lesions, canker sores are very painful and often make it hard to do simple activities like talking, eating and kissing.

Canker sores does not causes of bad breath. They are not contagious either, but its causes are not fully clarified. They seem to be caused by unbalances in the immune system.

Some of the known triggers are:

- Minor injuries like accidentally biting the lip
- Psychological stress
- Few sleeping hours
- Helicobacter pylori, the same bacteria that causes stomach ulcers
- Some toothpaste containing sodium lauryl sulfate
- Gastroesophageal reflux disease
- Foods such as chocolate, coffee and acidic drinks.
- Smoking
- Hormonal changes during the menstrual cycle.
- Deficiency of some vitamins and minerals such as vit.B12 and vit. C, zinc, iron and folic acid
- Drugs as: nonsteroidal antiinflammatory drugs (NSAIDs), rapamycin, methotrexate, Aspirin and Atenolol

Most aphthous ulcers last an average of 1 to 2 weeks and usually heal without scarring. Some people have big ulcers, called major canker sores, which are large lesions with irregular margins that can last months or even years. They often heal with extensive scarring.

There is still another type of aphthous ulcer called herpetiform canker sores, that are clusters of multiple tiny lesions that may merge to form a single large ulcer.

Canker sores may be accompanied by enlarged lymph nodes in the neck, and sometimes, of low-grade fever and malaise.

Canker sore

Canker sore treatment

There is no miracle treatment for canker sore. As it usually lasts up to 2 weeks, current treatments aim to accelerate the healing of the lesion.

It is important to distinguish ointments containing only anesthetics, and therefore serve only to relieve symptoms, from those with steroids and anti-inflammatory in its formula, which can effectively speed up the healing.

The 2 most commonly used drugs for this purpose are:
- Amlexanox (Aphthasol ®)
- Triamcinolone acetonide (Kenalog A ®)

The amlexanox has the best results in scientific papers.

In the Internet is very easy to find many homemade treatments for canker sores. One should be careful with these tips not to increase inflammation and worsen the lesion. Some acceptable options, but not as effective as the drugs described above, are:

- Rinsing your mouth with a solution of ½ teaspoon salt dissolved in 8 ounces of water.
- Another mixture that may be helpful consists of 1-2 tablespoons of Maalox (antacid containing Aluminium hydroxide and Magnesium hydroxide) mixed with ½ tablespoon of liquid diphenhydramine (Benadryl). Swish a teaspoonful in your mouth and spit it out. This can be done four times a day.
- You can also try over-the-counter products that contain a numbing agent, such as Orabase-B, Anbesol and Orajel

Avoid direct contact with abrasive substances such as alcohol and baking powder. This can irritate the injury and worsen the situation. When using dilutions for mouthwashes, always spit the liquid in the end. Never swallow.

When to worry about a canker sore

Although benign in the vast majority of cases, canker sore may be a manifestation of a systemic disease. Also, serious injuries, such as oral cancer can look like a simple ulcer.

A consultation with a dentist should be assessed when there are

- Canker sore in unusually large size
- Recurring ulcers, with new ones developing before old ones heal
- Persistent sores, lasting three weeks or more
- Signs of infection around the ulcer
- Systemic symptoms suggesting the presence of some disease
- Fever
- Genital ulcers associated

Which diseases can course with lesions similar to canker sores?

Usually, oral ulcers caused by systemic diseases are multiple and recurrent. They also have some different characteristics from simple canker sores and are accompanied by other symptoms.

In Lupus, for example, the ulcers are painless and accompanied by skin lesions and pain in joints.
In Behcet's disease, also an autoimmune disease, the lesions are multiple, recurrent and accompanied by eye injuries and ulcers on the genitals as well.

In celiac disease and Crohn's disease, canker sores come together with intestinal symptoms like diarrhea and bloody stools.

Neutropenia, which is a drop in the number of blood neutrophils (a type of white blood cell), also cause oral ulcers. It is usually seen in patients receiving chemotherapy, but can occur in any disease or drug that causes neutropenia. The ulcers are bigger than the regular canker sore.

Several infections can cause similar oral ulcers:

HIV patients can have oral ulcers in AIDS stages and also during the acute infection.

Coxsackie virus infection (herpangina), very common in children, can present with sore throat, fever, oral sores and lesions on the palms and soles.

Syphilis can present with oral ulcers. They are usually multiple and in secondary syphilis it takes a long time to heal.

Oral Herpes appears as blisters that can turn small ulcers after breaking up. The lesion is not very much like a canker sore, but can be confused by laymen.

Some cancers of the oral cavity may present as ulcerations and can initially be mistaken for simple canker sore. Therefore, every ulcer that takes time to heal should be evaluated by a doctor, especially if the patient is a smoker.

PNEUMONIA SYMPTOMS

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 22 Sep 2009 18:12:00 +0000

Spanish version: NEUMONÍA | Síntomas y tratamiento
Portuguese version: QUAIS SÃO OS SINTOMAS DA PNEUMONIA ?

Pneumonia is the name given to a inflammation of your lungs, usually caused by infection. To be more precise, pneumonia is an infection of the lung tissues and its alveoli.

But what are the alveoli?

Look at the figure below. The air we breathe comes through the nose / mouth and goes into the trachea. The trachea bifurcates to form the main branches left and right. They bifurcate several times to form the bronchioles, which ultimately end up in the alveoli.

The alveoli are microscopic structures that are in contact with blood. Through them the gas exchange take place. It's in the alveoli that oxygen breathed reaches the red blood cells.

When there is a pneumonia, the alveoli that should have only air within, is now filled with purulent secretions, preventing its normal operation. In these infected alveoli there are no gas exchange.

The more alveoli are affected, more extensive is the pneumonia and more severe is the situation.

Pneumonia can be caused, in decreasing order of frequency, by bacteria, viruses, fungi and parasites. It can range in seriousness from mild to life-threatening and is often a complication of another condition, such as the flu.

Our lungs are constantly exposed to germs from the air and from our own mouth's bacterial flora. We do not get sick all the time because the airways has defense mechanisms, which include cough, the immune system cells and the microscopic cilia in the bronchial tree that "sweep" the invaders out of the airways.

The development of pneumonia and its severity depend on the virulence of the invader, the amount of microbes that reach the lungs and immunological conditions of the patient.

Imagine now a patient with a reduced level of consciousness, which loses the ability to cough or swallow his own saliva. The airway of this person is exposed to an immense amount of secretions and microbes, favouring the development of pneumonia. A perfect example is someone who drank too much and is in a coma or pre-alcoholic coma.

A serious type of lung infection is aspiration pneumonia . It occurs, for example, in people who vomit and aspirate the contents. It also happens frequently during alcoholic coma.

Smokers have a constant irritation of the bronchial tree and dysfunction of cilia guards. Cell lung defense do not work properly too. All these factors favor the development of lung infections.

The main risk factors for pneumonia are:

- Age above 65 years
- Smoking
- Immunosuppressive diseases (HIV, transplant, cancer ...)
- COPD (chronic bronchitis and emphysema)
- Drug users
- Bedridden patients
- Patients with reduced level of consciousness
- Prolonged hospitalizations
- Patients on mechanical ventilation
- Patients with other lung diseases

And what are the symptoms of pneumonia?

The clinical manifestations of a patient with pneumonia include cough, fever, chills, shortness of breath, chest pain when you take a deep breath, vomiting, loss of appetite, malaise and body aches. There may be presence of bloody sputum. The fever in pneumonia is characteristically high, usually above 102º F (38.9º C).

Elderly patients may present a more subtle clinical picture, with little cough and low or no fever. Sometimes the only manifestation of pneumonia in this group is prostration and mental changes such as disorientation and confusion.

In severe cases, pneumonia can involve most areas of both lungs, making breathing difficult and depriving your body of oxygen. Sometimes acute respiratory failure is present and mechanical ventilation is needed.

Many patients with cough and sputum are afraid of tuberculosis. There are some differences between both diseases. Pneumonia develops fast and the patient feels very ill within a few hours of disease. Usually, in 24-48 hours the patient seeks medical attention. Tuberculosis has a more insidious presentation, with the disease gradually worsening and the patient often seeks medical attention only several weeks after the onset of symptoms.

The diagnosis of pneumonia is usually done by physical examination and a chest radiography. Blood tests, if readily available, can help, but they are not indispensable.

The alveoli filled with secretion appear as a white blur in the X-ray, as shown below.

Pneumonia are classified into 2 groups: community-acquired pneumonia and hospital-acquired pneumonia, being the latter more serious and more difficult to treat.

Pneumonia treatment

The treatment of bacterial pneumonia is done with antibiotics for at least 8 days. The decision to hospitalize or not, is made by the physician based on the severity of the symptoms. If you don't need oxygen supplementation nor parental antibiotics, you may recover as quickly at home with oral antibiotics as in the hospital

Antibiotics aren't effective against viral forms of pneumonia. And although a few viral pneumonia may be treated with antiviral medications, the recommended treatment generally is rest and plenty of fluids.

If your pneumonia is caused by a fungus, you should be treated with anti-fungal medication.

Pneumonia are common causes of sepsis and tend to be an important cause of death in the elderly and immunocompromised patient.

There is already a vaccine against pneumonia caused by Streptococcus pneumoniae, the most common bacterial pneumonia. It is recommended for people over 50 years, but does not prevent the pneumonia caused by other germs.

LEG CRAMPS

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 15 Sep 2009 14:41:00 +0000

Versión en Español: CALAMBRES | Causas y tratamientos
Portuguese version: TUDO SOBRE CÂIMBRAS

Muscle cramp is a spasm or involuntary contraction of a muscle, usually very painful, which can last from few seconds to several minutes. The cramp can achieve one or more muscles at once. Any of the skeletal muscles (muscles that can be voluntarily controlled) can present these contractions.

The most common are:
- Calves
- Anterior and posterior muscles of the thigh
- Feet
- Hands
- Neck
- Abdomen

It is believed that the cause of cramps is an excessive excitation of the nerves that stimulate the muscles. This is usually caused by:

- Vigorous physical activity (cramps may occur during or after exertion)
- Dehydration (specially in those who take diuretics)
- Hydroelectrolytic disturbance, particularly depletion of calcium and magnesium.
- Pregnancy (usually caused by low blood magnesium)
- As self-protection after a bone fracture, for example.
- Metabolic disorders such as diabetes, hypothyroidism, alcoholism and hypoglycemia
- Neurological diseases as Parkinson's, motor neuron disease and primary diseases of the muscles (myopathies)
- Long periods of inactivity, sitting in improper position.
- Structural changes such as flat feet and genu recurvatum (hyperextension of the knee)
- Renal insufficiency in hemodialysis
- Hepatic cirrhosis.
- Deficiency of vitamin B1, B5 and B6
- Anemia

Much has been said about potassium depletion as a cause of cramps. In fact, hypokalemia (low blood potassium levels) may cause involuntary contractions, but its main symptom is muscle weakness or paralysis. Calcium and magnesium are major causes of cramps.

Some drugs may be the cause:
- Diuretics, especially furosemide (Lasix ®)
- Donepezil (used in Alzheimer's)
- Neostigmine (used in myasthenia gravis)
- Raloxifene (used for osteoporosis and breast cancer)
- Medications for hypertension, especially nifedipine (Adalat ®)
- Bronchodilators for asthma as Salbutamol
- Medications for cholesterol such as clofibrate and lovastatin.

In those people over 60 years cramps can be sign of atherosclerosis, with decreased blood flow to a particular muscle group caused by obstruction of the flow due to cholesterol plaques

How to avoid cramps?

To avoid cramps you need a good session of stretching before and after exercise, especially for sedentary people. Another tip is to avoid exercise in very hot days and ensure good hydration before, during and after the effort.

There is a group of people who have night cramps, especially in the lower limbs (calf and feet in general). They usually have what we call idiopathic nocturnal cramps, which means night cramps without apparent reason. They are usually people with a family history of cramps and despite all investigation, you just can not detect any alteration to justify the symptoms

In this group, we recommend a daily 15-minute stretch program before bedtime. Priority should be given to foods rich in calcium and magnesium. It is crucial to maintain proper hydration throughout the day and avoid a sedentary lifestyle. Some people need special shoes to prevent involuntary contractions.

Stretching seems to be the best way to prevent cramps, especially when they occur in the legs. It is important to emphasize that it takes at least a few weeks with daily stretching to notice some results.

Proper hydration and frequent stretching, solve the problems of the majority of people with idiopathic cramp, ie, those that are not caused by any specific disease. The best way to control the degree of body hydration is through urine appearance. When we are not well hydrated, our urine becomes dark yellow with a strong smell, whereas a hydrated body produces clear and odorless urine (read: WHY DOES MY URINE SMELL SO BAD?).

There are some drugs such as vitamin E, B complex, verapamil, chloroquine and gabapentin that may help in specific cases, but it should only taken after medical evaluation.

Tonic water has small amounts of quinine, a substance which also appears to prevent cramps. There are reports of improvement of night cramps after a few days drinking tonic water at night.

Patients on hemodialysis often have cramps. A cramp is a sign of reduced blood flow to the affected muscle. It usually occurs when there is excess ultrafiltration during the sessions or by high doses of antihypertensive drugs. Patient with cramps that do not use antihypertensive drugs should increase its dry weight (weight after the dialysis session). Patients with cramps using drugs for hypertension, should reduce the dose.

What about bananas for cramps?

Banana is rich in potassium, carbohydrates (glucose) and water. During exercise there is a great muscles demand for energy (glucose). After some time of exercise the muscle depletes its reserves of glucose and begins to use other means to generate energy, like burning fat. One reason for cramps is the accumulation of lactic acid, which is the "garbage" that we produce after energy generation without glucose. Good hydration helps to "wash" the excess lactic acid circulation and prevents cramps.

Therefore, theoretically eating banana helps because it restores potassium levels, hydrates and provide energy to the muscles. This is true for exercise-induced cramps. However, this tip does not work with many people. The result seems to be individual, but as a banana is just a fruit and does not cause any harm, it is worth trying.

GOUT AND URIC ACID

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 08 Sep 2009 13:02:00 +0000

Portuguese version: SINTOMAS DA GOTA E ÁCIDO ÚRICO
Spanish version: GOTA | ÁCIDO ÚRICO | Síntomas y dieta

Gout is a disease characterized by episodic attacks of arthritis (gouty arthritis) caused by high blood levels of uric acid.

Uric acid is a substance produced in the liver, derived from the metabolism of purines, a type of protein present in our body and in the food we eat. The higher the intake of purines, the greater the production of uric acid by the liver.

During the evolution of species, humans lost the ability to produce an enzyme called uricase that converts uric acid into allantoin, a substance much more soluble in blood. As a result, humans have uric acid levels much higher than most other mammals and requires the kidney to eliminate it efficiently, preventing its accumulation.

Our normal blood levels of uric acid are very close to the limit of solubility, and small increases in its concentration is enough to cause the formation of tiny crystals that deposit in tissues of the body. Uric acid precipitates in the form of sodium urate.

Uric acid is more soluble at temperatures above 37 º C, which is the temperature of the blood. However, in our joints, the temperature is lower (touch on his knee and compare with the temperature of the thighs or legs) which favors the deposition of crystals in these places.

Summarizing: Uric acid stays dissolved in the blood until blood levels around 7 mg/dl. From this value, the higher the concentration, the greater the chances of crystallization and deposition in tissues. It occurs primarily in the joints, and, as the blood level rises further, any tissue can be affected.

It is important to notice that it takes a few years of high uric acid levels to develop gout symptoms. It not happens in the short-term

Gout symptoms

Whenever there is deposition of urate crystals in joints, there is an inflammatory reaction, leading to a very painful arthritis. Intense inflammation occurs as white blood cells engulf the uric acid crystals activating chemical messengers of inflammation leading to pain, heat, and redness of the joint tissues.

Gouty arthritis is typically an extremely painful attack with a rapid onset of joint inflammation.
The arthritis is so painful that some patients can not even cover his feet with the blanket because it is enough to precipitate a very strong pain.

The arthritis crisis occurs mainly in one joint at a time, specially in the joint of your big toe, but it can occur in your feet, ankles, knees, hands and wrists. It is basically a monoarthritis, but in advanced stages it may involve more than one joint.

During gout crisis, there may be chills and fever.

Gouty arthritis of the big toe, notice the swelling and redness of it.

The attack of gout lasts a few days, usually 10, and then disappears even if untreated. The discomfort subsides gradually over two weeks, and leaves the joint apparently normal and painless.

The interval between the first and second crises can last up to 2 years. If untreated, the gout gets more frequent and severe, and may affect more than one joint at a time.

Over the years the untreated gout leads to the formation of tophi (singular: tophus) in the joints, caused by chronic deposition of urate crystals, leading to deformities as shown in the photos below. This stage is called tophaceous gout. Tophi usually aren't painful, but they can become swollen and tender during gout attacks.

The high level of uric acid can also lead to kidney uric acid stones and development of tophi in the kidneys, leading to renal failure (read: KIDNEY STONES SYMPTOMS AND CAUSES)

As explained before, gout is caused by prolonged high blood levels of uric acid. However, not everyone with hyperuricemia, develops gout symptoms. Some people remain years with uric acid levels greater than 7 mg/dl and not have gout or kidney disease. Why this happens, we do not know.

Gout is much more common in men and usually occurs between the ages of 40 and 50. Women generally develop signs and symptoms only after menopause.

The main risk factors for gout are:

- Obesity
- Hypertension
- Trauma
-Long periods of fasting
-Consumption of alcohol
-Use of drugs that increase uric acid, such as diuretics
- Family history
- Great intake of purine rich foods

Purine rich foods are:

Meat: bacon, pork, veal, lamb, mutton, offal (liver, heart, kidney, tongue)
Fish and seafood: salmon, sardines, trout, cod, fish eggs, caviar, shellfish, oysters, shrimp.
Birds: turkey and goose
Alcohol

Foods with moderate amounts of purines:

Meat: beef, veal and rabbit
Poultry: Chicken and duck
Seafood: Lobster and crab
Legumes: beans, chick peas, peas, lentils, asparagus, mushrooms, cauliflower, spinach

Foods with low or no purine content:

Milk, tea, coffee, chocolate, cheese yellow skinny, hard-boiled eggs, cereals such as bread, pasta, corn, potatoes, rice, maize, cassava, sago, vegetables (cabbage, cauliflower, lettuce, spinach and watercress), nuts, sweets and fruit (even the acid ones)

The diagnosis of gout is made by the association of clinical manifestations and high blood levels of uric acid. When in doubt, your doctor may use a needle to draw fluid from your affected joint to look for signs of urate crystals deposition.

Treatment and remedies for gout

The treatment of gout is divided into 2 stages: Treatment of acute arthritis and prevention of future crises. There is no cure for gout, but it can be very well controlled.

During the gout crisis, patients are treated with regular anti-inflammatory drugs (NSAIDs)and/or colchicine. Sometimes steroids are needed.

Colchicine is less toxic than NSAIDs (specially to kidney and stomach) and controls gout effectively, but may cause uncomfortable side effects, such as nausea, vomiting and diarrhea.

Aspirin-containing medications, when possible, should be stopped, because aspirin prevents kidney excretion of uric acid.

Once the crisis is over, the treatment aims to decreased levels of uric acid. The most widely used drug for this purpose is Allopurinol. It is important to emphasize that one should not get Allopurinol during crises, due to the risk of worsening it. If the patient already uses it, there is no need to suspend it.

We suggest the patient to keep taking colchicine to prevent new crises while the levels of uric acid have not been reduced by allopurinol. It may take a few months of treatment to achieve desirable values.

As most people with high uric acid levels do not develop symptoms, the current consensus not to indicates allopurinol unless the patient has already had any gout crisis or kidney stones. The exception are those asymptomatic patient with uric acid levels above 13 mg/dl in men or 10 mg/dl in women.

Febuxostat is a new drug approved by the U.S. Food and Drug Administration (FDA) for the chronic management of hyperuricemia from gout. Febuxostat has been shown to be more effective than allopurinol in preventing acute attacks of gouty arthritis and is effective in shrinking tophi deposits of uric acid in the tissues such as the fingers, elbows, and ears.

Cherry juice for gout

Cherries have been associated with lower levels of uric acid in some studies, but it isn't clear if they have any effect on gout signs and symptoms. It is not a FDA approved treatment, but its consumption does not appear to cause any harm. So, adding cherries to your diet may be a safe way to supplement your gout treatment but you should never depend solely on it. Drugs are still needed for gout.

With a proper diet, weight reduction and therapy to reduce uric acid levels, the patient can get rid of the crisis and prevent kidney damage and joints.

HEMATURIA - BLOOD IN URINE

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 01 Sep 2009 17:00:00 +0000

Hematuria refers to the presence of blood in the urine

There are some ways to characterize it:

- Macroscopic or visible hematuria (gross hematuria) or microscopic hematuria (only detected in urine tests)
- Hematuria with or without clots.
- Dysmorphic or monomorphic hematuria (explained below).
- Persistent or intermittent hematuria.
- Isolated hematuria or followed by other signs and symptoms
- Painless hematuria or painful hematuria

A person may have hematuria due to bleeding at any point in the urinary tract, including the kidneys (where urine is made), the ureters (the tube from the kidneys to the bladder), the bladder, the prostate or the urethra (the tube from the bladder to the outside of the body)

The main causes are:

- Cancer (kidney, bladder, prostate)
- Kidney stone (read: KIDNEY STONES SYMPTOMS AND CAUSES )
- Urinary tract infection (read: URINARY TRACT INFECTION - BLADDER INFECTION )
- Prostatic hyperplasia (benign enlargement)
- Glomerulonephritis (read: GLOMERULONEPHRITIS )
- Sickle cell anemia
- Polycystic kidneys
- Trauma
- Drugs
- Urinary Tuberculosis
- Physical exertion
- Hypercalciuria (increased urine calcium levels)
- Loin pain-hematuria syndrome

You can notice that there are multiple causes and that's why the investigation is not always simple.

It is noteworthy that women during the menstrual period may have signs of hematuria in her urine tests. Actually this is not real hematuria, just contamination of the sample. If possible, we must avoid doing urine tests during menses.

Sometimes the signs and symptoms that follows hematuria, make the diagnosis easier:

- Young women with burning or aching urine (dysuria) => Cystitis.
- Fever, chills and vomiting => Pyelonephritis.
- Intense pain radiating to the groin => Kidney stone
- Elderly with a weak urine stream => Benign prostatic hyperplasia

Sometimes the past medical history helps, such as in sickle cell disease, trauma, medications, kidney stones or physical effort.

Painful hematuria usually indicates urinary infection or kidney stone while painless hematuria is common in all other causes.

When there is no apparent cause, the investigation is more complex.

The first step is to discriminate whether the blood comes from the glomerulus (kidney cells) or elsewhere in the urinary tract.

Urine tests can detect dysmorphic erythrocytes, which are damaged red blood cells. Those damaged cells usually come from the glomerulus ant its presence indicates glomerulonephritis.
Patients with glomerular hematuria should always be referred to a nephrologist.

The presence of blood clot is an evidence of bleeding outside the kidney and virtually excluded the diagnosis of glomerulonephritis.

If the glomerular origin is excluded, a radiological investigation with ultrasonography or computed tomography is the next step. Depending on your doctor's suspicion, he can start with image exams before the investigation of dysmorphic erythrocytes.

Urinary cytology is an important exam to detect the presence of cancer cells in urine and the cystoscopy (a small tube with a camera is inserted into the bladder through the urethra) to look for bladder tumors.

Hematuria can also occur after intense physical exertion. It has have no clinical significance.

Isolated hematuria in young people, which means, without other symptoms or signs and with no change in creatinine blood levels (read: DO YOU KNOW WHAT CREATININE IS? ), are benign situations at most of the time. It should only be monitored regularly, as well as any transient hematuria without apparent cause.

Urinary or prostate cancer must always be discarded in people over 50 years, in smokers, people with weight loss or bone pain.

When a glomerular disease is suspected it is often necessary to perform a renal biopsy to identify the disease that is affecting the kidney.

The loin pain-hematuria syndrome is not a well understood disorder characterized by recurrent or persistent loin (flank) pain and hematuria that appears to represent glomerular bleeding.
Most patients present with both manifestations, but some present with loin pain or hematuria alone. The hematuria in is typically characterized by dysmorphic red cells, which indicate a glomerular origin.

As many as 35% of children with apparently idiopathic hematuria (no infection and negative radiologic evaluation) have hypercalciuria, while up to 20% of children with recurrent hematuria have hyperuricosuria, both disorders are often associated with a positive family history of stone disease. These children are at increased risk for the future development of kidney stones. Similar findings may be present in adults.

Rare causes of hematuria include hereditary hemorrhagic telangiectasis, radiation cystitis, schistosomiasis, arteriovenous malformations and fistulas and nutcracker syndrome.

It is important to know that a dark, orange or red urine might not always mean blood. Only the urine test is that it can confirm the presence or absence of hematuria (read: CHANGES IN URINE COLOR )

There is no specific treatment for hematuria. Rather, treatment is aimed at the underlying cause.

Portuguese version: HEMATÚRIA ( URINA COM SANGUE )

DO YOU KNOW WHAT CREATININE IS?

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 25 Aug 2009 10:04:00 +0000

Spanish version: CREATININA Y UREA ALTA
Portuguese version: VOCÊ SABE O QUE É CREATININA ?

- What is creatinine?
- Do you know if your kidneys are working well?
- Do you know that kidney failure is asymptomatic until late stages of the disease?
- Do you know that a simple and inexpensive blood test called creatinine can identify the kidney disease in its initial phase?
- So, do you know what is your creatinine level ?

Chronic kidney disease (CKD) is a worldwide public health problem. There is a rising incidence and prevalence of kidney failure in almost all countries.

Until the end of this decade, there will be in the U.S.A, more than 600.000 patients with end stage renal disease. The major concern is the fact that only half of these individuals have knowledge of their disease.

Many diseases can lead to chronic kidney disease, but 6 of them are responsible for the majority of cases:

- Hypertension
- Diabetes
- Polycystic kidneys
- Glomerulonephritis (read: GLOMERULONEPHRITIS )
- Recurrent urinary tract infections (read: URINARY TRACT INFECTION - PYELONEPHRITIS )
- Kidney stones (read: KIDNEY STONES SYMPTOMS AND CAUSES )

You may be thinking:

- My kidneys are good, they don't ache, I don't feel any pain when a I pee, and my urine has good volume and appearance.

As I said before, the chronic kidney disease does not usually cause symptoms until well advanced stages of disease. Most patients who need to start hemodialysis still have a good urine volume. The urine aspect alone does not tell if the kidneys work perfectly. Of course, if you have blood or a very foamy urine, you might have renal disease, but don't rely solely on these symptoms specially if you have one of the diseases described above.

When we talk about the urine volume, you must know that the control of body water is just one of the many functions of the kidneys. The renal system also act on:

- Excretion of blood substances as drugs or toxins
- Control of blood levels of electrolytes such as potassium, sodium, magnesium, calcium and phosphorus.
- Production of hormones that stimulate the red cells production
- Heath of bones and vitamin D activation
- Control of blood coagulation system
- Control of blood pH
- Control of blood pressure

It's important to know that renal failure is not a cause of renal or back pain!

The pain usually occurs in cases of pyelonephritis (infection of the kidneys), kidney stone or urinary obstruction. If you have end stage renal disease, but not because of those, you won't feel any pain at all. So again, don't rely on pain to diagnose renal problems.

OK I see. So, how do I know if my kidneys are working properly?

2 simple and inexpensive tests can be done:

- Determination of creatinine and urea (BUN) levels in blood.
- Urine tests

And who should take these tests?

- People with hypertension and/or diabetes
- Age above 60
- Family history of glomerulonephritis or polycystic kidney disease
- Family history of end stage renal disease
- Chronic use of non-steroidal anti-inflammatory drugs (NSAID)
- Recurrent urinary tract infection
- History of renal stones speccially if more than once)
- Diffuse or focal edemas (swelling)
- Anemia without apparent cause.
- Severe cardiac disease, especially heart failure
- Signs of bleeding or foamy urine
- People with weight loss, nausea, weakness, loss of appetite without apparent cause.
- Treatment with potentially nephrotoxic drugs
- Obesity or metabolic syndrome
- Smokers
- People with Hepatitis C virus infection
- People with HIV infection
- Cancer

The creatinine is a chemical waste molecule that is generated from muscle metabolism. It is filtered and eliminated by the kidneys. When they are not working well, the levels of creatinine rises. As it is generated by the muscles, the strongest you are, the highest will be your basal levels of creatinine. So, you don't expect an old lady to have the same levels as a young athlete.

Normal levels of creatinine in the blood are approximately 0.6 to 1.2 mg/dl (71 to 106 µmol/L)But it's a result that must be interpreted by your doctor. If you have a large mass of muscles it can be a little higher and still be normal. If you are very thin old women, a result of 1,2 mg/dl is probably too much for you and might indicate renal failure.

With the creatinine levels in hands, your doctor can do a simple calculation and find out the glomerular filtration rate (GFR), which is the actually the rate of blood filtration.

Normal kidneys filtrates 180 liters of blood per day (120 ml per minute). When GRF falls bellow 60 ml/min we call it established chronic kidney disease.

As the kidneys stop working, there are only 2 options, dialysis or kidney transplantation. The early referral to nephrologist (kidney specialist) can slow the progression of kidney failure and avoid unpleasant outcomes for the patient and his family.

GLOMERULONEPHRITIS

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 18 Aug 2009 09:56:00 +0000

Glomerulonephritis is the name given to a group of kidney diseases caused by inflammation of the glomeruli.

Okay, I know that the sentence above does not explain much.

The fact is, to understand glomerulonephritis, we must first understand what is a glomerulus.

The microscopic anatomy of the kidney is very tricky, and can be hard to understand even to other physicians.

Let's try to make it easier.

All our organs are composed of its basic units. We have neurons in the brain, hepatocytes in the liver, alveoli in the lungs, etc ... In the kidney, the basic unit is the nephron.

Each kidney has one million nephrons. These microscopic units are responsible for filtering the blood and for the substances produced in the kidneys. A nephron is not a single cell, but a structure composed of a glomerulus and their renal tubule.

This "simple" graphic below represents a nephron with its glomerulus, renal tubule and blood vessels.

We can summarize the functioning of the kidney as follows.

The blood that reaches the kidneys, goes to the glomerulus, which is capillary tuft, with a filtrating membrane in its wall. The glomerulus is actually our true blood filter.

Glomerulus seen by electron microscopy

Look at the graphic below. The blood reaches the afferent arteriole (a microscopic artery), passes through several capillaries in the glomerulus, undergoes the process of filtration and then returns to the bloodstream via efferent arteriole.

Everything that has been filtered by the capillaries goes toward renal tubule. In the renal tubule, some important substances such as glucose, sodium, potassium, calcium etc ... are reabsorbed in accordance with the needs of the body. The final result of this process is the urine as we know it. The kidneys just excrete substances unneeded or in excess.

The glomerulus is the leading filter, "choosing" which substances go to the urine and which return to the blood. The tubules in turn, define how much of each substance already filtered by the glomerulus will be excreted in the urine. For example, if there is high potassium in the blood, the tubules will eliminate all the potassium that is filtered to restore its normal levels. On the other hand, if the blood potassium is low, then the tubules will avidly reabsorb it, leading to a urine with very little potassium in it.

Major substances such as most of the proteins, are not filtered at all, because they are larger than the pores of the glomerular membrane. They never leave the blood and do not reach the tubule. Therefore, a normal urine has almost no protein in its content.

So, the final content of urine, is a result of both the process of glomerular filtration and tubular reabsorption.

So, as glomeruli are the main responsible for the filtration of blood, any disease affecting it, disturbs the main function of our kidneys.

There are 2 basic types of glomerulus injury:

- Nephritic syndrome or glomerulonephritis.
- Nephrotic syndrome

In nephritic syndrome, an inflammatory process damages and reduces the capacity of the glomerulus to filter blood, leading to acute renal failure, hypertension and bloody urine (hematuria)

In nephrotic syndrome, the most common is a glomerular membrane injury without obvious sighs of inflammation.

To better understand, we can say that, in glomerulonephritis, the glomerulus filters it all. Nothing passes through the membrane. while in the nephrotic syndrome, it all passes. The proteins that are normally not filtered, when there are lesions on the membrane of glomeruli, "leak" into the tubules, being inappropriately eliminated in the urine.

Loss of protein in urine, called proteinuria, is a sign of glomerular disease. Indeed, proteinuria is a sign of kidney disease, but is also responsible for its progression. The tubules are not prepared to receive large amount of proteins, and in attempt to reabsorbs them back to the blood, its cells suffers damages.

Therefore, at first, the presence of protein shows that there is something going wrong with the kidneys. If untreated, it becomes another factor of aggression and progression to renal failure.

It is not uncommon to find nephrotic syndrome and nephritic syndrome at the same time. All it takes are concomitant lesions in the glomerular membrane and intense inflammatory activity in the glomerulus. In medical practice it is very common to see some overlapping between these two syndromes

So, what causes glomerular disease?

The glomerular diseases have several causes. Didactically it is divided into primary disease, when there is no apparent cause, or secondary disease, when they occur due to any systemic condition.

Secondary causes of glomerulopathy (nephritis and/or nephrotic):

- Lupus
- Hepatitis B and C
- HIV
- Diabetes
- Morbid obesity
- Heroin
- Syphilis
- Wegner Granulomatosis
- Goospasture Disease
- Cancer
- Pharyngitis or skin lesions caused by Streptococcus (post infectious glomerulonephritis)
- Amyloidosis

Primary glomerulopathy:

- Focal and segmental Glomerulosclerosis (nephritic syndrome and / or nephrotic)
- Disease minimal damage (nephrotic syndrome)
- Membranous nephropathy (nephrotic syndrome)
- Membranoproliferative Glomerulonephritis (nephritic syndrome and / or nephrotic)
- IgA nephropathy (nephritic syndrome)

We call primary glomerulopathy those glomerular diseases restricted to the kidney. There are no other organs or systems affected.

Each of these glomerular diseases, primary or secondary, has distinct clinical features, prognosis and treatment. Therefore, the specific diagnosis of the glomerular injury and the recognition of the presence or absence of associated systemic disease is vital to the treatment.

Blood analysis may reveal kidney failure by showing an increasing creatinine level (read: DO YOU KNOW WHAT CREATININE IS? ). The urinary loss of proteins leads to a foamy urine and a low level of blood proteins such as albumin. The physical examination can easily identify hypertension and edemas.

These factors only suggest the presence of a glomerular disease, without establishing a specific diagnosis.

Obviously, if a patient has hepatitis C and suddenly starts to show signs of glomerulopathy, the cause of renal damage is easy. But most of the time it is not that simple. Some diseases such as lupus can cause different types of glomerulonephritis and glomerular injury, and different types of signs and symptoms, requiring different treatments for each.

The gold standard in the diagnosis of glomerulopathy is a renal biopsy. The biopsy in addition to defining the type of glomerulonephritis, also provides indications of the prognosis of the disease.

As most glomerulonephritis and glomerulopathy have immunological factors, sometimes related to autoimmune diseases, treatment is based on heavy immunosuppressive drugs such as corticosteroids, cyclophosphamide, cyclosporine, azathioprine and mycophenolate mofetil . If the biopsy identifies very advanced lesions and little chance of cure, treatment often brings more complications than improvement.

Several factors interfere with the prognosis. Some diseases such as minimum lesion and IgA nephropathy are usually benign or have very slow progression. Others like lupus nephritis or glomerulonephritis secondary to Wegner's Granulomatosis are very severe and can easily lead to end stage renal disease.

The glomerulopathy are just behind the Diabetes and hypertension as causes of end stage renal diseases.

If you have any sign that might suggest a glomerular disease, especially blood or protein in the urine (even in small quantity), it might be good to seek a nephrologist.

Portuguse version: O QUE É UMA GLOMERULONEFRITE ?

WHY DOES MY URINE SMELL SO BAD?

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 11 Aug 2009 09:55:00 +0000

Spanish version: ORINA CON OLOR FUERTE
Portuguese version: URINA COM CHEIRO FORTE

The urine shows a characteristic odor that is caused by the presence of urea. The higher the concentration, the stronger is its smell. In most cases, a bad smelly urine indicates a insufficient diluted urine. In general, it appears as a dark yellow urine.

The first step, therefore, is to increase the intake of liquids. There is no magic number. It depends on many factors as temperature, exercises frequency, types of food you eat, drugs you are taking, etc...

Sometimes, it takes up to 3L of water per day. Besides improving the smell, a diluted urine prevents the formation of kidney stones. The more dilute it is, the less is the chance of the crystals in urine to gather and form a stone.

If the urine is well diluted and still stinks, you should consider the presence of bacterias that normally metabolize urea into ammonia, a substance that has much stronger odor.

You should distinguish the mere presence of bacteria in the urine of urinary infection. You can have bacteria in urine as you have it on your skin and mouth, for example.

But, if you have symptoms such as burning sensation and need to urinate all the time, even with the bladder empty, it indicates the treatment with antibiotics. If the bacteria in the urine are causing odors but no sigh or symptoms of infection, the decision to treat is more controversial.

If the smell is strong and very unpleasant, I would try a single course of antibiotics, if we are dealing with a healthy person with no history of other diseases.

Certainly I'd try the antibiotics only once. If the symptoms return after a time, treat it again with a new course of antibiotics would increase the risk of creating resistant bacteria.

Indeed, I have not found any description in the medical literature about what to do in this case.

Apart from urinary tract infection, urethritis and in some STD can also cause bad smell.
Women with STD tend to be less symptomatic and a bad smelly urine may be the clue to the diagnosis. Men often have purulent discharge from urethra, which makes the diagnosis easier.

In women, one possibility is that a vulvovaginal infection, like bacterial vaginosis or candida vulvovaginitis (yeast infection) could be the reason for the smell. A consultation with a gynecologist can rule out vaginal infections and urethritis.

If you have already ruled out bacterias or any other type of infection, there are other causes to investigate.

Medicines and foods that can alter the smell of urine. Asparagus is the most well known, but it can happens with alcohol, coffee and vitamins as well. Some antibiotics, especially the family of penicillin can cause smelly urine. Changes in diet can improve this.

Diabetes can also cause urine odor, specially if you are not controlling your sugar levels well. We do not expect that a smelly urine would be the first symptom of diabetes. In general, the patient has already others symptoms such as weight loss, weakness, thirst, high urine output (polyuria) etc... Hardly a bad smelling urine would the only finding.

In older people, cancer and bladder fistulization to the intestine caused by diverticulitis or other inflammatory diseases, may be the cause. The cancer is usually associated with hematuria (blood in urine), while the fistula, as there is a connection between the bladder and the colon/rectum, can lead to a symptom called pneumaturia, which is the release of the intestinal gases through the urine. In this case, the urine smells as faeces. With the fistula, there can be passage of urine per rectum as well

Some rare genetic diseases with phenylketonuria can also be the reason for odors, but they are diseases of neonates.

If the odor is something that bothers you a lot, I suggest consulting a urologist or gynecologist to elucidate the case

KIDNEY STONES SYMPTOMS AND CAUSES

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 04 Aug 2009 09:50:00 +0000

Portuguese version: CÁLCULO RENAL (PEDRA NOS RINS)

Do you know what causes kidney stones? What are the symptoms?

kidney stones, also known as nephrolithiasis or urolithiasis, is a very common disease, affecting 5% of world population. If the UTI is more common in women, the stones affects mainly men

To Understand how a kidney stone is formed is crucial to learn how to prevent new cases.

Over 80% of stones are composed of calcium salts, mainly calcium oxalate and calcium phosphate. Other less frequent types are uric acid (read: GOUT AND URIC ACID), struvite (magnesium ammonium phosphate), and cystine stones.

What causes kidney stones ?

Imagine a glass of water. Pure water is clear and transparent. Now, if you throw some salt in the water, it will dilute and disappear. If you keep throwing more and more salt, the water becomes cloudy to point where the salt begins to precipitate at the bottom of the cup. This happens when the amount of solvent (water) is not sufficient to dissolve all the solute (salt). Every solute needs a specific amount of water to stay soluble

This is the principle of formation of the kidneys stones. When the amount of water in urine is not sufficient to dissolve all the salts present, they return to their solid form and precipitate along in the urinary tract.

Therefore, to simplify a complex process, we can say that the formation of calculi occurs when there is lack of solvent (water), excess of solute (salt), or even both. The substances not diluted form crystals, which become anchored in the kidney and gradually increase in size, forming a kidney stone.

Now, that is not difficult to understand why the majority of kidney stones occur due to little intake of fluids. People with a family history of nephrolithiasis should urinate at least 2L per day. It is not practical to measure your daily urine., so a simple tip is to watch the color of the urine. A well diluted urine is bright yellow, almost transparent like water (read: CHANGES IN URINE COLOR )

A diluted urine solves the problem of most people with kidney stones. However, there is a group of patients that even drinking plenty of water, continues to form stones. Those are the ones with disturbances in their urinary composition. They have excess of solutes in their urine.

This is the most important concept of the text. Everyone with more than 1 episode of kidney stone should be investigated for metabolic disorders that cause excess solute in the urine.

If you have recurrent nephrolithiasis and had never investigated the etiology, it's time to look for a nephrologist. Depending on your problem, there are drugs that can prevent new stones.

Sometimes, a simple change in your diet can prevent the appearance of new stones. You might be thinking: OK, if the stones are formed mainly by calcium, and you are saying that excess of solute causes kidney stone, so, all I have to do is consume less calcium. That's well thought, but that's wrong.

The excess of calcium in the urine has nothing to do with your diet. It's an intrinsic problem of the kidneys. Now imagine, if you are losing calcium in the urine, and you are not consuming enough to replace it, what do you think will happen? That's right, your blood calcium will be low and your body will start to take calcium off your bones to maintain a desirable level.

So, if you have recurrent kidney stones, you should start drinking more water while you wait for your appointment with a nephrologist

Recurrent kidney stones are one of the most common causes of chronic renal failure. Therefore, it is not just a matter of dealing with the pain, you can actually lose your kidney if don't seek for help.

What are the symptoms of a kidney stone?

Symptoms of a kidney stone usually occur when the stone passes from the kidney into the ureter (the tube that leads from the kidney to the bladder). Excruciating back pain, blood in the urine (hematuria), passing small stones in the urine, nausea or vomiting, and the urgent need to urinate are common symptoms of kidney stones.

The pain is usually described as the worst the patient ever had. It starts in the back and irradiates toward the groin. Typically, the pain waxes and wanes in severity. Waves of severe pain, known as renal colic, usually last 20 to 60 minutes, although less severe pain can be present between episodes of renal colic.

Fever is not an expected symptom and its presence suggests an associated infection.

Many patients with kidney stones have no symptoms at all. The stones are accidentally found when an imaging study (such as an ultrasound, x-ray or CT scan) is performed for other purposes.

How to diagnose a kidney stone?

Clinical symptoms, laboratory tests, and imaging studies are usually used to diagnose a kidney stone.

When it's not the first stone, it's easier to establish the diagnosis. Actually, most of the times the patients comes to the doctor already knowing the diagnosis.

CT scan , ultrasonography and abdominal x-ray are the most commons image exams performed. The former is the best one. Blood and urine tests can help in the differential diagnosis.

Kidney stone treatment

The initial treatment consists of powerful analgesics and fluids. If the stones are smaller than 0,5 cm, they might pass spontaneously within the next hours. If the stones are 1 cm or bigger, they will not pass and further treatment is required.

The options are:
- Shock wave lithotripsy (SWL)
- Percutaneous nephrolithotomy (PNL)
- Ureteroscopy

Your doctor will decide between one of them depending on your case

URINARY TRACT INFECTION - PYELONEPHRITIS

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 28 Jul 2009 10:00:00 +0000

The urinary tract includes the kidneys, bladder, or the urethra (the tube that carries urine out of the bladder). When the infection attacks the bladder we call it cystitis. When it attacks the urethra it called urethritis. This text is about pyelonephritis, the infection of the kidneys.

The cystitis was already addressed in the text: URINARY TRACT INFECTION - BLADDER INFECTION

Acute pyelonephritis is a urinary tract infection that has progressed from the lower urinary tract, usually from the bladder, to the upper urinary tract (kidneys)

There are 2 main ways to get a kidney infection. The main route is when bacteria in the bladder reach the ureters and climb up to the kidneys. This normally occurs in untreated cystitis, but asymptomatic colonization, without signs of bladder infection can also be the source. Not all people reports symptoms of cystitis before the onset of pyelonephritis.

The second way is when the bacteria reach the kidney from the blood. It happens we have a infection in a distant point of the body, like a skin infection, for example, and those bacteria manage to travel into the bloodstream and lodge in the kidneys. This route is much less frequent than the former.

The pyelonephritis is a potentially fatal disease. We are talking about a infection of a vital organ. It can be as severe as a pneumonia. If it's not treated on time, it can lead to sepsis and death.

As I have already said in the cystitis text, the mere presence of bacteria in urine without any symptoms urinary infection, should not be treated. There is no way to know in advance which people with bacteria in the urine will develop cystitis or pyelonephritis. As reinfection is very common, if we prescribe antibiotics every time we find a bacteria in the urine, we'll promote development of resistant strains.

The presence of bacteria in urine is called bacteriuria, which is different from the presence of bacteria causing infection. We have bacteria all over our body. They colonizes without infecting our mouth, skin and intestine, etc...

Therefore, there is no indication to treat asymptomatic bacteriuria. It does not indicate any kind of disease.

There are 3 exceptions to this rule:

- Pregnant women: The isolation of bacteria in the urine increases the risk of pyelonephritis, premature delivery and babies born with low weight.

- Before urological procedures: Patients who are undergoing surgery or urological procedures, should treat their bacteriuria, since this practice reduces the risk of bacteremia and sepsis after surgery.

- immunosuppressed patients.

The pyelonephritis can be divided into 3 categories:

- Acute uncomplicated pyelonephritis

- Acute complicated pyelonephritis

- Chronic pyelonephritis

1) Acute uncomplicated pyelonephritis

It usually occurs in young women with no history of disease or abnormalities in urological anatomy. The clinical manifestations of acute uncomplicated pyelonephritis include flank pain, abdominal or pelvic pain, nausea, vomiting, high fever, chills, and/or costovertebral angle tenderness.

A burning sensation when urinating, the classic symptoms of cystitis, might not be present. As in cystitis, the main bacterial responsible for pyelonephritis is Escherichia coli.

Hospitalization is only indicated in severe cases. If the patient is well and is able to take oral antibiotics, treatment can be done at home.

2) Acute pyelonephritis complicated

It is called complicated pyelonephritis when the infection evolves with renal abscess or peri-renal, or necrosis of the renal papilla.

It usually occurs in people with urinary tract obstruction, bacteria resistant to antibiotics and diabetes.

The initial clinical picture is similar to the uncomplicated pyelonephritis, but it shows little response to antibiotics. One might also suspect complicated pyelonephritis when there is only partial response, with fatigue, malaise and nausea lasting for several days.

Pyelonephritis which does not improve after appropriate antibiotic therapy should be studied with imaging tests such as CT and ultrasound (ultrasound)

3) Chronic pyelonephritis

The chronic pyelonephritis manifests as a recurrent urinary tract infection associated with malformation of the urinary tract, obstruction by kidney stone or vesicoureteral reflux (reflux of urine from the bladder back into the ureter and kidney).

Chronic pyelonephritis often lead to chronic renal failure, especially in children with reflux.

The treatment of any urinary infection should always be done with antibiotics. There is no other way to get rid of the bacteria.

Portuguese verson: PIELONEFRITE (INFECÇÃO DOS RINS )

URINARY TRACT INFECTION - BLADDER INFECTION

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 21 Jul 2009 10:02:00 +0000

Portuguese version: INFECÇÃO URINÁRIA (CISTITE)
Spanish version: INFECCIÓN URINARIA | CISTITIS

Let's talk about urinary infection, a very common disease, especially in females. 60% of adult women will have at least one episode of urinary tract infection (UTI) during their lives.

There are 2 types of UTI:

Cystitis => bladder infection.
Pyelonephritis => infection of the kidneys (read: URINARY TRACT INFECTION - PYELONEPHRITIS )

Indeed, there is a third type, which is urethritis, usually caused by sexually transmitted diseases. But that is subject to another topic.

This time I'm going to write about cystitis, which is the infection of the bladder.

While cystitis is a relative simple problem, a pyelonephritis may lead to sepsis and death by widespread infection. In general, pyelonephritis occurs when the bacteria in the bladder reaches the kidney through the ureters.

Look at both pictures of male and female urinary tract, to better understand its anatomy.

While urinary tract infection is rare in men, except in young children and in elderly, women spend the entire life under the risk of infection.

To find out why it happens, it's necessary to understand a little bit of our anatomy and the pathophysiology of this infection.

The first important information is that over 80% of UTI are caused by a bacteria that usually lives in our intestine, called Escherichia coli (E.coli). In the colons, most subtypes of E.coli causes no harm. The infection occurs when, for some reason, these bacteria are able to colonize the area around the vagina, going into the urethra and reaching the bladder.

E.coli is the most common agent, but many other bacteria of the intestinal tract can also cause cystitis.

Take a look at the pictures below. They show the anatomy of man and woman.

Notice that the urethra in women is smaller and its entry much closer to the anus than is in men. Man's urethra is longer, which requires that the E.coli travels a longer distance in order to reach the bladder.

For obvious reasons, anal sex is a risk factor for UTI in men, as you bring intestine bacterias right to the entry of urethra.

Now you might be thinking:

- Well, if a UTI is caused when a bacteria normally found in faeces, colonizes the area around the vagina, all I have to do is wash my vagina very well in order to kill these intruders and prevent bladder infection.

Unfortunately, that is not what happens.

The fact is that, women's vagina has its own bacterial flora. For a bacteria from the anus colonize the region, it must compete with those already living on site. When you wash your vagina many times a day or when you use special disinfectant products, you kill the natural flora of the vagina, facilitating the process of colonization of foreign bacteria that are coming from the anus

So, what should be done to prevent urinary infections ?

- Keep the genital area clean, but don't over clean it. You should pay special attention when cleaning up after the evacuation. Whipping must always be done from front to back, in the opposite direction to the vagina.

- Take showers rather than bathtubs.

- NEVER perform direct vaginal shower. This will push the bacteria into the bladder.

- Avoid using deodorant sprays or feminine products in the genital area.

- Always urinate after sexual intercourse. The intercourse promotes entry of bacteria into the urethra.

- Drink enough liquid to urinate frequently and expel the bacteria from the bladder and urethra.

- Do not use condoms which contain spermicides.

- Indiscriminate use of antibiotics can also alter the natural flora of the vagina and facilitate infections.

- Women at menopause should use estrogen based vaginal creams to reduce dryness and local traumas.

For those who like natural products, Cranberry demonstrably reduces the risk of infection. You can have cranberry juice or take the pills now for sale in drugstores.

And how can I know if my symptoms are derived from a cystitis ?

The irritation of the bladder causes typical symptoms. The most common is a burning sensation when urinating, called dysuria. Others symptoms include, darkened, cloudy, strong-smelling or bloody urine, urge to void, even with the bladder is empty, discomfort in the pelvic area and low-grade fever.

Some people associate a strong-smelling urine with urinary tract infection. This is not necessarily true. The main reason for a bad-smelling urine is lack of water in it. The more concentrated the urine is, the stronger will be the odor. If your urine is dark yellow and has a very strong smell, you should drink more liquids to dilute it. This usually resolves the problem and help prevent the formation of kidney stones.

When the symptoms are typical, some doctors prefer treatment without the request of any examination. Others, if readily available, ask for a rapid analysis of urine to confirm the presence of pus. But it's not wrong at all to treat without asking any exam.

Regardless of conduct, cystitis should always be treated with antibiotics to prevent recurrences and progression to pyelonephritis. In general, only a 3 days course are sufficient.

The biggest concern is to avoid the bacteria from reaching the kidneys and causing a pyelonephritis. The clinical picture is of high fever, back pain, chills, nausea and vomiting. In this case treatment should be at least for 7 days and blood and urine tests are needed. In severe cases, treatment should be given intravenously.

Despite all the precautions listed above, some women have recurrent urinary infections. Those are generally people with genetic predisposition. Some may benefit by taking 1 tablet of an appropriate antibiotic after sexual intercourse. In severe cases, with several UTI a year, you may need longer courses (up to 1 year) of antibiotics.

Another option is the Uro-Vaxom, a kind of vaccine with 16 different strains of E.coli. It seems that the use of this product for 3 months reduces the occurrence of cystitis. Note that this drug only works for those who have recurrent infections of the E.coli. That's for sure not the solutions of all infection, but it can really help in some cases.

CHANGES IN URINE COLOR

noreply@blogger.com (Dr. Pedro Pinheiro) — Tue, 14 Jul 2009 10:08:00 +0000

Spanish version:COLOR DE LA ORINA
Portuguese version: URINA COLORIDA

The urine colour can be a sign of disease or just an interesting finding with no clinical significance.
This text explains the main reasons for changes in usual urine colour.

Dark yellow or brown urine : The normal urine colour varies from clear yellow to dark yellow. If you are well hydrated, your urine will be clear. A dark yellow urine is usually a highly concentrated one, due to dehydration a lack o water to dilute it.

In some liver diseases like in hepatitis there may be excretion of bilirubin in urine. The presence of bilirubin turns urine into a dark colour, like Coca-Cola.

Presence of blood (hematuria) can also lead to dark yellow urine.

Purple Urine : It's usually caused by urinary infection. Most of the time from bacteria that alkalizes the urine. It is a rare finding. It occurs more in patients hospitalized and with bladder catheter.

Orange urine: An orange urine is usually a diluted red urine (see red urine below). Concentrated urine is usually very strong yellow, but can also be orange. Ingestion of beets, carrots and wild blackberries or drugs as Rifampin can also turn urine to orange.

Green urine : It's usually caused by ingestion of dye. It can also occur with drugs such as amitriptyline, indomethacin and propofol. Ingestion of asparagus and artificial colors as methylene blue can lead to green urine. Eventually, some bacteria can also be the cause.

Red urine and pink urine: red urine is usually a sign of bleeding (hematuria), but may also be caused by medicines and foods.

Laxatives, especially those with Sena in its formula, Rifampin, Pyridium, vitamin B, beets and berries. Anticoagulants such as warfarin and heparin, can lead to hematuria and consequently to red urine. A disease called methemoglobinemia can also be the cause.

A red urine when very diluted, can appear as pink or orange.

Blue urine: this urine color is usually caused by ingestion of drugs and dyes such as methylene blue. Drugs described as causes of blue urine includes, Triamterene, amitriptyline, indomethacin and Viagra.

There is a genetic metabolic disease, called blue-diaper syndrome, which causes blue urine in neonates.

Black Urine: Caused by another rare genetic disease called alkaptonuria.

Regardless of color, the appearance of urine may be a clue to identify an early disease.

Urine with an excess of foam suggests the presence of protein (proteinuria), which is a sign of kidney disease. A milky ou cloudy urine may indicate the presence of pus. A smelly urine indicates that this is very concentrated and facilitates the formation of kidney stones.

A healthy urine is clear yellow, almost transparent, odorless, with a small amount of foam and does not cause pain or discomfort when urinating.